There are 5.5 million people in the US with Alzheimer?s disease or related dementias (ADRD). Annual health care expenditures for this population are $259 billion with the majority of these costs attributed to ADRD patients receiving long-term care in nursing homes (NHs). Due to the cognitive decline and the behavioral and psychiatric symptoms experienced by ADRD patients, there are few substitutes for long-term care provided by NHs. Nearly two-thirds of NH residents have some degree of ADRD, over 60% of whom are dually-eligible. NH residents with ADRD have high rates of hospitalization (45.8%/year) and emergency department visits (55.3%/year). Up to 80% of these events are associated with ambulatory care sensitive conditions, which are potentially preventable with appropriate primary care in the NH. However, earlier research has indicated that dual-eligibles receive primary care of lower quality than other beneficiaries. Once a patient becomes a long-stay NH resident, the NH physician becomes his/her primary care provider. As the primary care provider, the NH physician is expected to deal with problems as the patient?s dementia progresses, to refer appropriately, to coordinate with other providers, to initiate and follow up on treatment issues, and to work with family members overseeing the patient?s care. The Medicaid Primary Care Fee Bump provides a natural experiment to examine the impact of higher physician reimbursement on the quality of care for dually-eligible NH residents with ADRD. Over a two-year period (2013-2014), the initiative required states? Medicaid programs to reimburse providers the same rates as Medicare for primary care services for all Medicaid patients. For dual-eligibles, the fee bump required Medicaid programs to reimburse providers the full 20% Medicare coinsurance for primary care services, which included evaluation and management services provided in NHs. Prior to the fee bump and following its expiration, states covered 0 to 20 percentage points of Medicare Part B coinsurance. Using a national sample of all dually-eligible NH residents with ADRD over an eight-year period (2011-2018), this project will take advantage of the natural experiment created by the Medicaid Primary Care Fee Bump to identify the impact of higher reimbursement for primary care services on the quality and cost of care for these beneficiaries. This will be done using two sources of variation: (1) the timing of both the implementation and termination of the fee bump and (2) variation in the states reimbursing physicians the full 20% Medicare coinsurance for dual-eligibles before and after the fee bump. The quasi-experimental nature of the research design will allow estimation strongly indicative of causation and our national sample of all dually-eligible long-stay NH residents with ADRD will help ensure that the results are generalizable. The project will provide highly valuable evidence indicating whether increased reimbursement for primary care services in NHs improves the quality and/or lowers the cost of care for dually-eligible residents with ADRD. This issue has immediate policy relevance as 31 states did not maintain higher reimbursement rates for these services after the fee bump expired at the end of 2014.
Using a unique natural experiment, the proposed project will be the first to quantify the impact of higher provider reimbursement for primary care delivered in nursing homes on the quality and cost of care for dually-eligible residents with Alzheimer's disease and related dementias (ADRD). It will also be the first study to quantify the impact of higher reimbursement for primary care services on racial disparities in the quality of care among nursing home residents with ADRD.
